Posts Tagged ‘reducing hospital readmissions’

Decreased hospital readmissions leads to improved patient outcomes, which improves brand reputation, ultimately leading to increased patient volume and market share. Reducing readmissions begins with creating a seamless care transition plan for what will happen within the hospital as well as after discharge, according to a new infographic by the Studer Group.

The infographic examines how reducing readmissions impacts a hospital’s bottom line and techniques to improve care transitions.

A care transitions management program operated by Sun Health since 2011 has significantly reduced hospital readmissions for nearly 12,000 Medicare patients, resulting in $14.8 million in savings to the Medicare program. Using home visits as a core strategy, the Sun Health Care Transitions program was a top performer in CMS’s recently concluded Community-Based Care Transitions (CBCT) demonstration project, which was launched in 2012 to explore new solutions for reducing hospital readmissions, improving quality and achieving measurable savings for Medicare.

Hospitals can’t just leave patient care to chance after patients leave the hospital. They must be more actively involved in managing their patients to ensure that they will receive the most appropriate post-acute care and avoid readmissions, according to a new infographic by eviCore healthcare.

The infographic examines the components of the post-acute healthcare market, guidelines for avoiding unnecessary readmissions and strategies for modernizing post-acute care.

A tri-county, skilled nursing facility (SNF) collaborative in Michigan is holding the line on hospital readmission rates for the three competitive health systems participating in the program.

Henry Ford Health System, Detroit Medical Center and St. John’s Providence, along with the state’s Quality Improvement Organization (QIO), MPRO, developed standardized quality reporting metrics for 130 SNFs in its market. The SNFs, in turn, enter the quality metrics into a data portal created by MPRO.

During Reducing SNF Readmissions: Quality Reporting Metrics Drive Improvements, a 45-minute webinar on May 11th at 1:30 p.m. Eastern, Susan Craft, director, care coordination, family caregiver program, Office of Clinical Quality & Safety at Henry Ford Health System, will share the key details behind this collaborative, the impact the program has had on her organization’s readmission rates along with the inside details on new readmission reduction target areas born from the program’s data analysis.

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Transitioning eligible patients to hospice can help hospitals avoid Medicare’s 30-day readmission penalty, according to a new infographic by VITAS.

The infographic examines how hospice can reduce readmission rates and increase patient satisfaction.

A tri-county, skilled nursing facility (SNF) collaborative in Michigan is holding the line on hospital readmission rates for the three competitive health systems participating in the program.

Henry Ford Health System, Detroit Medical Center and St. John’s Providence, along with the state’s Quality Improvement Organization (QIO), MPRO, developed standardized quality reporting metrics for 130 SNFs in its market. The SNFs, in turn, enter the quality metrics into a data portal created by MPRO.

During Reducing SNF Readmissions: Quality Reporting Metrics Drive Improvements, a 45-minute webinar on May 11th at 1:30 p.m. Eastern, Susan Craft, director, care coordination, family caregiver program, Office of Clinical Quality & Safety at Henry Ford Health System, will share the key details behind this collaborative, the impact the program has had on her organization’s readmission rates along with the inside details on new readmission reduction target areas born from the program’s data analysis.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

Seventy percent of healthcare organizations providing care to patients in their homes attributed a reduction in either hospital readmissions or in ER utilization to those home visits, according to the December 2016 Home Visits survey by the Healthcare Intelligence Network.

A new infographic by HIN examines the populations targeted by home visits, the primary purpose during a home visit and a promising home visit protocol.

Visiting targeted patients at home, especially high utilizers and those with chronic comorbid conditions, can illuminate health-related, socioeconomic or safety determinants that might go undetected during an office visit. Increasingly, home visits have helped to reduce unplanned hospitalizations or emergency department visits by these patients.

2017 Healthcare Benchmarks: Home Visits examines the latest trends in home visits for medical purposes, from populations visited to top health tasks performed in the home to results and ROI from home interventions.

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Medicare’s billing codes for Transitional Care Management (TCM) highlight the importance of timely post-discharge contact with patients by provider offices, and timely face-to-face follow up and evaluation by TCM providers. Incorporating automated patient communications can facilitate efficient and effective handoffs, and support a consistent track of care to help providers earn TCM reimbursements and avoid hospital readmission penalties, according to a new infographic by West Healthcare.

The infographic looks at the financial impact of reducing readmission penalties and examines how automated patient communications can improve care transitions.

Sun Health, an Arizona non-profit organization, launched its Sun Health Care Transitions program in November 2011. Modeled after the Coleman Care Transitions Intervention® and adapted to meet the needs of its community, the program has been credited with keeping readmission rates well below the national average.

Sun Health’s program was part of the Center for Medicare and Medicaid Services’ National Demonstration Program, Community-Based Care Transitions Program, which ended in January. Not only did Sun Health lead the CMS demonstration project with the lowest readmission rates, Sun Health also widened the gap between their expected 30-day readmission rate (56 percent lower than expected) and their expected 90-day readmission rate (60 percent less than expected).

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The importance of care transitions in improving patient safety is illustrated by recent data released by The Joint Commission on sentinel events compiled from January 2014 to October 2015.

The data show a total of 197 sentinel events—from suicide to falls to wrong site surgery—and the root causes included failures in patient communication (127 incidents), patient education (26 incidents) and patient rights (44 incidents). The majority of the patient education failures were related to not assessing the effectiveness of patient education or not providing education. The patient rights failures included absent or incomplete informed consent, and lack of the patient’s participation in their care.

In response to these findings, the Joint Commission released an infographic to help healthcare providers in their efforts to reduce patient readmissions and improve the discharge process.

Providers who signed on for San Francisco Health Network’s Care Transitions Task Force shared not only a professional passion for care transitions work but also the belief that care transitions responsibility should be spread across the healthcare continuum. And once the SFHN task force mined a ‘black box’ of administrative data buried in more than 60 siloed databases across its health network, continuum-wide care transition improvement seemed attainable.

While hospitals report they are confident in their ability to reduce readmissions, according to a new survey conducted by Q-Centrix, the percentage of hospitals penalized for readmissions has increased each year since CMS began imposing them.

The percentage of hospitals penalized for readmissions reached a high of 78 percent for FY 2015. Given the historical trend and the three additional diagnoses recently added, the percentage of hospitals penalized will likely be much higher than the 55 percent who reported that they expected to be penalized, according to an infographic produced by Q-Centrix on the survey results.

While great strides have been made in the reduction of 30-day all-cause hospital readmissions, CMS still penalized more than 2,200 hospitals in 2013 for exceeding 30-day readmission rates for heart failure, pneumonia and myocardial infarction. This year, CMS penalties extend to acute COPD and elective hip and knee replacements.

From home sensors that monitor daily motion and sleep abnormalities, to video visits using teleconferencing, Humana is doing its best to ensure that the frail elderly can remain at home as long as possible.

When integrated with a telephonic care management program, these remote monitoring technologies have helped Humana to avert medical emergencies and preventable hospitalizations among individuals with serious medical and functional challenges, says Gail Miller, vice president of telephonic clinical operations in Humana’s care management organization, Humana Cares/SeniorBridge. The pilots are part of a continuum of care aimed at improving health outcomes, increasing satisfaction and reducing overall healthcare costs with a more holistic approach.

Despite their growing frailty, however, nine out of 10 Americans prefer to age at home, she continues. To help them live independently and age gracefully at home, Humana, which has over 30 years experience in the Medicare program, and over two and a half million Medicare advantage members, launched the Humana Chronic Care Program (HCCP). Targeting the members most in need, or the sickest 20 percent, which drive 75 percent of the company’s costs, the company implemented a series of nine healthcare remote monitoring pilots for individuals with congestive heart failure (CHF) and diabetes as well those with medication adherence problems. The pilots also target those with functional challenges that make activities of daily living (ADL) challenging.

One of the pilots includes strategically placed home-based sensors that monitor ADL levels of those with functional impairment. Algorithms detect abnormalities in the patients’ activities, i.e. erratic sleeping behaviors or toileting patterns that can signal infections, which then generate alerts for recommended interventions.

Video visits include two way audio-video communications so that care managers can interact with their sickest members as an adjunct to home visits. Members are given tablets to use for face-to-face contact with their care manager, or to go over any educational materials their care managers or physician provides them.

Ranging from passive to active monitoring, all of the technologies are senior-friendly, and designed to help members manage their conditions, reduce hospitalizations and improve the patient/member experience, Miller says.

A mobile Personal Emergency Response System (PERS), for those that live alone or have limited caregiver support, has been the most popular, Miller says. Members are mailed a cellular device that can be activated manually by a button, or automatically via an accelerometer. Once turned on, the PERS device connects the member to clinically trained emergency support. Many patients have asked if they could extend their use of this particular device once the pilot was over, Miller says. She explains why:

Besides being a health issue, I think the device also speaks to the level of safety concerns that a lot of seniors who have multiple chronic conditions, and who live alone, have. They don’t want to necessarily reach out to their neighbors all the time. This provides them some peace of mind, which is the ultimate goal of the program.

What are your organization’s efforts in remote patient monitoring? Participate in our e-survey, 10 Questions on Remote Patient Monitoring, by April 22, 2014 and you will receive a free summary of survey results once it is compiled.

Development of post-acute partnerships with home health, skilled nursing facilities (SNFs) and hospice is emerging as a key strategy to stem hospital readmissions, according to new market data from the fourth annual Healthcare Intelligence Network (HIN) Reducing Hospital Readmissions Survey.

More than half of survey respondents participate in post-acute partnerships, with home health collaborations the most common (79 percent). These partnerships serve to streamline processes and care transitions, educate and align staff, and implement changes of value to patients, respondents say.

Looking at more conventional approaches, medication reconciliation and telephonic monitoring of patients post-discharge emerged as frontrunner strategies to curb readmissions. Moreover, the 2013 survey revealed significant upticks in the use of each tactic over 2012 levels: medication reconciliation is now conducted by 73 percent of respondents, versus 54 percent in 2012, while the use of telephonic monitoring jumped from 48 to 71 percent over the same 12-month period.

In other new data, almost half of respondents  47 percent  aim programs at individuals already assessed at high risk for readmission as well as traditional Medicare (53 percent), Medicaid (28 percent) and high utilizer (23 percent).

Other key findings include the following:

Two-thirds of respondents to HIN’s December 2013 Readmissions e-survey have a program to reduce readmissions.

In a new metric from the 2013 survey, more than half  52 percent  aim readmission reduction efforts at individuals with diabetes.

Heart failure remains the top condition targeted by programs, although a fifth already track readmissions for hip and knee replacements, a metric the Centers for Medicare and Medicaid Services (CMS) will examine more closely in 2015.

Call it a bouncer of sorts for the emergency room: the readmissions prevention manager, or RPM for short, has helped Torrance Memorial Health System reduce all cause readmissions by nearly 5 percent, and earn its hospital system kudos from the industry, says Josh Luke, Ph.D., FACHE, vice president of post acute services at Torrance Memorial Health System and founder of the California Readmission Prevention Collaborative and the National Readmission Prevention Collaborative.

He shared the key features of this program, which was recognized by California Association of Healthcare Facilities as a Program of Excellence in 2013. At the time, the 401-bed not-for-profit hospital was achieving readmissions rates that were in step with national averages, generally within 18 to 20 percent, and some quarters exceeding that. Torrance felt it could do better, approaching the problem from an all-cause, rather than disease-specific perspective, Luke says.

Creating the RPM was the first step in the process, he says. This person would function as the leader of the hospital readmission prevention team, making sure only patients who meet criteria and need to be hospitalized are admitted either to the observation floor or to the inpatient unit.

As Luke explains: the RPM gets a real-time email alert any time a patient comes to the ER and their social security number is entered into the hospital’s electronic system. Their number one priority is then to go right to the ED to meet the patient and work with the attending doctor, case manager and nursing team in the ER to see if this patient can be cared for at a lower level of care.

That’s essentially what the Affordable Care Act has encouraged us to do and incentivized us to do and penalized us when we don’t do that efficiently, which is not to admit patients to the hospital that don’t need to be here. We are very encouraged by the success of that program in its initial six months.

The RPM then follows those patients who were not admitted to the ED to a post-acute network facility, at all times keeping in mind patient choice. TWT includes a post-acute network of eight skilled nursing facilities (SNFs), all within five miles of the hospital, and a home health agency. Along with a home health department navigator, the RPM goes to each SNF once a week to follow up on patients, determining discharge plans and employing an ambulatory case manager if the patient goes to a home health agency outside the Torrance network, and keeps tabs on them long after the 30-day readmission period is over.

Collaboration and communication with the post-acute network (PAN) is key to success, Luke says. “Whenever I’m asked if I could name three basic things to prevent readmissions, the first thing I always refer to is telling your skilled nursing facilities to invest in predictive software because it doesn’t cost you as a hospital anything. It enables you to share data with the SNFs.”

That, and always be a champion of choice for your patients, Luke adds, even when they’re being bounced out of the ER.

Download this FREE report for data on the top clinical targets of healthcare case managers; the top means of identifying and stratifying individuals for case management; and the most common locations of embedded or colocated case managers.